Provider Demographics
NPI:1790121911
Name:OTTO, JENNIFER (RPH)
Entity Type:Individual
Prefix:
First Name:JENNIFER
Middle Name:
Last Name:OTTO
Suffix:
Gender:F
Credentials:RPH
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:
Other - Last Name:ONDRUS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RPH
Mailing Address - Street 1:11059 LAUREL HILL DR
Mailing Address - Street 2:
Mailing Address - City:ORLAND PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60467-8730
Mailing Address - Country:US
Mailing Address - Phone:708-220-5792
Mailing Address - Fax:708-448-8598
Practice Address - Street 1:12416 S HARLEM AVE
Practice Address - Street 2:
Practice Address - City:PALOS HEIGHTS
Practice Address - State:IL
Practice Address - Zip Code:60463-1441
Practice Address - Country:US
Practice Address - Phone:708-671-1200
Practice Address - Fax:708-448-8598
Is Sole Proprietor?:No
Enumeration Date:2013-05-14
Last Update Date:2013-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX32024183500000X
IL051291032183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist